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2/18/18
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Brian P. Mahoney, OD, FAAODepartment of Veterans Affairs
Wilmington, [email protected]
Financial Disclosure
I have nothing to disclose
Top 10 cancers in the US
1. Skin2. Lung
3. Prostate4. Breast
5. Colorectal6. Kidney7. Bladder
8. Non-Hodgkin's Lymphoma9. Thyroid
10. Endometrial
Who gets cancer? Lifetime risk of developing cancer in U.S.*
Men Women
All invasive sites 1:2 1:3
Lung 1:14 1:17
Colon 1:21 1:23
Breast 1:769 1:8
Prostate 1:7 ---
Skin Melanoma 1:38 1:61
* Surveillance Epidemiology and End Result (SEER) database 2010-2012
Lifetime risk of dying from cancer in U.S.*
Men Women
All invasive sites 1:3 1:5
Lung 1:16 1:20
Colon 1:50 1:55
Breast 1:3333 1:37
Prostate 1:39 ---
Skin Melanoma 1:233 1:476
* Surveillance Epidemiology and End Result (SEER) database 2010-2012
1:4 deaths in the US is
attributed to cancer
When are people diagnosed with cancer?70% of patients diagnosed with cancer
are between ages 55 and 85
Distribution for cancer diagnosis by state What is cancer?
- not 1 specific “disease” but a group of diseases
- characterized by uncontrolled/ abnormal growth of cells
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Cancer spreadLocally by invasion of surrounding tissue
Distally through bloodstream/lymphatic circulation
How often does systemic cancer affect the eye
0.7% reported by Godtfredsen in 1944 4.7% reported by Albert et al in 1967
Between 15- 42% have known primary
1/3 of patients with orbital metastasis have no previous diagnosis of cancer
Metastatic involvement to the eye
Direct involvement by metastasisChoroid most common ocular structure involved
90% of choroidal metastasis inposterior pole
>70% are single lesions but may have multiple
Choroidal melanomaVarying pigmentation
(creamy to heavily pigmented)
Elevated with dome shape
Overlying and/or adjacentserous detachment
Ultrasonography “hollowness”
2% in 1 year
9% in 5 years
13% in 10 yrs
Nevus vs. Melanoma TFSOM Mnemonic
T = Thickness >2 mm
F = Fluid
S = Symptoms
O = Orange pigment
M = Margin touching ONH
1 feature has 38% chance of growth in 5 years
2 or more have 50% chance of growth in 5 years
Iris metastasisSolid in appearance with
Cream/pink in color
Frequently seen in isolation
Frequently seen inferiorly due to shedding of tumor
cells
Ciliary Body metastasisDisplaces the iris root
forward
Feeder vessels may be observed
May only be visible after pupillary dilation
Poor prognosis due to dx at late stage
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Optic nerve involvementDisc swelling c/s retinal hemes
Significant drop in VA
VA improves with treatment
Poor prognosis given advanced disease status
Clinical symptomsDiplopia 48%Pain 42%Vision loss 30%
Clinical findingsProptosis 63%Strabismus 62%Vision loss 49%
PrimaryBreast 29%Melanoma 20%Prostate 13%
CT Location Orbital fat 43%EOM 28%
Reported survival was 28% at 18 monthsfollowing diagnoses of orbital metastases
Orbital metastasis considerations
41 yo WF experiencing gradual blur OU when reading for 3 mos which started after
her last exam 5 mos prior to exam
States use of lubricant drops w/o any improvement of vision
Chemotherapy treatment for stage 4 breast cancer x 2 years
Blurred vision and dry eye
Perrl (– ) APD
No motility abnormality
BVA OD: 20/30 (subjective blur OD/OS) OS: 20/30 (was 20/20 OD/OS 5 mos earlier)
Confrontation VF : Some facial blur OD /OS
Anterior segment and fundus: Unremarkable
Pertinent clinical findings
Intracranial metastasis considerations
Optic radiations
72 yo WM with 2 day onset of horizontaldiplopia evaluated in local ER previous day
Discharge diagnosis:- right VI nerve palsy from diabetes - recommend eye evaluation if it gets worse
2 year history of DM
1 year history of Stage 4 squamous carcinoma of soft palate s/p surgery,chemotherapy and radiation
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OD eso posture with leftabduction deficit
No APD
BVA 20/30 OD 20/20 OS
Mild ptosis OS
Dilated exam:Sharp disc margins No diabetic retinopathy
Intracranial Involvement
Constellation of neurologic deficits
Elevated ICP, CN palsy, motility
Paraneoplastic syndromes
Seen in less than 1% of cancer patients.
Most commonly associatedwith lymphoma, lung,
ovarian and breast cancers
Results from humoral ORantigenic response to the cancer
Ocular involvement of PNSCONDITION ANTIGENIC TARGET
Carcinoma associated photoreceptorsretinopathy (CAR) (cones)
Melanoma associate bipolar cellsRetinopathy (MAR)
Bilateral diffuse uveal tissuemelanocytic uveal Proliferation (BDUMP)
CARMay precede dx of
cancer by months to years
Painless vision loss over weeks to months
Relatively normal appearance to fundus/possible disc pallor
Photoreceptor loss on OCT macular scan
Basics of cancer treatment
Curative treatment options are offered when possible.
The primary goal of treatment for metastatic disease is to control the rate of growth and offer symptomatic relief
when possible
Most people that die of cancer, succumb to their metastatic disease
.
Radiation of ocular structures
External beam radiation Radio plaque implant
Available and accessible
Time commitment:5 days/week30 min sessions3-10 week course
Surgical implant and removal within 3 days
Only available in a few locations
(ie: Ocular Oncology Service at Wills Eye)
Radiation terminology
Rad: amount of energy absorbed by 1 Kilogram of living tissue
Gray (Gy)= 100 Rads
1 Gy= 100 cGy
Chest x-ray= 1 cGy
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Dosages for radiation treatment Ocular tissue tolerance of radiation
Ophthalmic and adnexal complications of radiotherapy. Shane R. Durkin,Daniel Roos, Braden Higgs, Robert J.Casson and Dinesh Selva. ACTA Ophthalmologica Scandanavia 2007.
Scleral atrophy 10 yrs post brachytherapyACTA SCANDANAVIA
2007
Eyelid involvement from radiation treatmentCondition Duration
Erythema Temporary
Malposition Temporary or permanent(entropion/ectropion)
Madarosis Temporary (possible permanent >50Gy)
Trichiasis Variable
Ocular sequella of local radiation
Anterior segment:EyelidsLacrimal system
mild to KCS
ConjunctivaCorneaScleraLens
Time to onset of ocular xerophthalmia
< 30 Gy: not commonlyseen
30–45 Gy: 4–11 years
> 57 Gy: corneal NV/apparent 10 mos
Potential xerophthalmia treatments
Ocular lubricant gtts/ung
Restasis/Xiidra?
Surgical proceduresie: Tarsorraphy ?
Autologous serum drops?
Manifestation of radiation damage
63 yo BM with knownCNS lymphoma
Had head radiation over 13 month period
OD OS
9/22/2006 20/20 20/208/24/2009 20/20 20/203/10/2012 20/25 20/25
(dx with CNS Lymphoma, radiation started )10/24/2012 20/40 20/404/22/2013 20/80 20/80
(Last dose of radiation received 04/2013)7/1/2013 20/400 20/4009/9/2013 CF CF5/23/14 CF CF
6 mos
afterrad
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OD
OS
7/2013: 3 months after d/c radiation with a total of 5000 Gy
Risk for radiation retinopathy increases with direct absorption of >45 Gy
Scleral atrophy 10 yrs post brachytherapy
Radiation retinopathy1 yr post orbital radiation
Sequella from previous radiationtreatment may manifest months to years following completion of radiationtreatment in distant past.
Chemotherapyand
the eye
Incidence of complications from chemotherapy
38% of reported involvement is rare
16.4% common or somewhat common
No reported incidence- howeverunder-estimation and
under-reporting is suspected due to other life
threatening situations
Chemotherapy
53 yo BF diagnosed with breast CA 1 year ago
Treated with tamoxifen for past year
Wants glasses for reading
Pertinent case findings
BVA 20/20 OD 20/20 OS with subjective blur
No APD
Fundus findings…....
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2017
2017
2011
Medscape 2016: Cancer Control. 23 (2):150-6. ISSN 1526-2359
EpiphoraParul & Abhishek. Journal of Cancer Therapeutics & Research 2012,http://www.hoajonline.com/journals/pdf/2049-7962-1-5.pdf
Visual/Ocular involvement of chemotherapy Patient education and preemptive Tx
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Immunotherapy approach to treatment
Advances in treatment of Chronic lymphocytic leukemia (CLL)
BCL-2 is a protein involved in the apoptotic process and certain forms of cancer (ie: CLL) modifies the BCL-2 functionality thereby preventing the body to kill off the cancer cells.
Our role in caring for patients diagnosed with cancer is far
greater than detecting a choroidal melanoma!
Optometry role in caring for patients with cancer diagnosis
Patient education- Potential ocular/visual involvement- Need for prophyllactic management
Palliative care- Provide prophylactic lubricants- Known radiation
total dose and ocular involvement- known chemotherapy
Thank you!
